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The Annals of Thoracic Surgery, Vol 58, 30-32, Copyright © 1994 by The Society of Thoracic Surgeons
MS Bains, RJ Ginsberg, WG Jones 2nd, PM McCormack, VW Rusch, ME Burt and N Martini
Median sternotomy has been the accepted approach for dealing with
mediastinal tumors or bilateral pulmonary disease, but exposure to the
lower lobes and to mediastinal tumors extensively involving a hemithorax is
often limited. Based on the reported experience from double-lung
transplantation, we explored the use of clamshell incisions for these
difficult problems. From March 1991 to December 1993, we prospectively
studied the utility of clamshell incisions in 90 patients for the following
indications: bilateral pulmonary metastases (62 patients), primary lung
carcinoma with mediastinal involvement (13 patients), primary tumors of the
mediastinum (14 patients), and mesothelioma (1 patient). Bilateral anterior
thoracotomies with a transverse sternotomy (clamshell incision) were
employed in 71 patients and a unilateral anterior thoracotomy with partial
or complete median sternotomy (hemiclamshell incision) was used in 19
patients. For closure, we used pericostal sutures and sternal wires,
usually augmented by sternal K-wire stents or Steinmann pins to prevent
sternal override. Exposure to all areas of the mediastinum, pericardium,
pleura, and lung was excellent. Specifically, the clamshell incision
afforded markedly better access to lower lobe disease and hemithoracic
extension of mediastinal disease than that possible with median sternotomy.
There were no deaths or significant morbidity, and all patients tolerated
the incisions well without mechanical respiratory difficulties. There was
one wound infection. There was no late sternal override and the cosmetic
results were found to be excellent during a follow-up of 2 to 33 months. We
conclude that clamshell incisions constitute an improved surgical approach
for the management of bilateral pulmonary or combined pulmonary and
mediastinal disease.
ARTICLES
The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York.
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